Provider Demographics
NPI:1124116231
Name:MCCLANAHAN, RAY A (DPM)
Entity type:Individual
Prefix:
First Name:RAY
Middle Name:A
Last Name:MCCLANAHAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 NW 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209
Mailing Address - Country:US
Mailing Address - Phone:503-243-2699
Mailing Address - Fax:503-243-2698
Practice Address - Street 1:725 NW 19TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209
Practice Address - Country:US
Practice Address - Phone:503-243-2699
Practice Address - Fax:503-243-2698
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPO00000596213E00000X
ORDP00317213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
R119239Medicare ID - Type Unspecified
U66176Medicare UPIN